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What
You Need to Know About Contracting and Credentialing
To help with understanding
how our process works, we've answered some of the most frequently asked
questions we receive about credentialing and contracting. This information
is a general guideline for solo practitioners. If you have specific questions,
please contact SJMMBH directly.
Q. What do I have
to do to be an in-network provider with SJMMBH?
A. SJMMBH makes provider network determinations based on specialty and geographic
needs. To be an in-network provider, you must be both credentialed and
contracted by SJMMBH. Only if both the credentialing and contracting processes
are completed can you be considered a SJMMBH in-network provider eligible
to see members and be reimbursed in accordance with the applicable reimbursement
schedule(s).
Q. What is credentialing?
A. Credentialing is the process we use to review and verify and periodically
re-review and re-verify your professional credentials in conjunction with
SJMMBH's credentialing criteria.
Q. What does the credentialing process include?
A. The credentialing process includes, but is not limited to:
- Primary Source
Verification (PSV) - Through PSV, we verify the information provided
regarding the status of your license, insurance, education and training
with state agencies, accrediting bodies and other applicable entities.
- Credentialing Committee
Review - If your credentials pass PSV, your application is sent to the
Credentialing Committee consisting of SJMMBH clinical staff and professional
peers in your area. The Credentialing Committee reviews applications
subject to applicable state laws and our business needs.
Q. How long does
the credentialing process take?
A. National Committee for Quality Assurance (NCQA) guidelines allow 180
days to credential providers. Because the PSV process requires verification
from external sources, we sometimes need the full 180 days to complete
credentialing. However, some states and client contracts require a shorter
credentialing time and we have processes in place to help meet those requirements.
Q. How will I be
notified if I am accepted into the SJMMBH networks?
A. Upon successfully completing the credentialing process, you will receive
a letter welcoming you to the SJMMBH provider network pending execution
of your provider agreement.
Q. Will I be notified
if I am not accepted into the SJMMBH provider networks?
A. Yes. You will receive a letter explaining why your application could
not be accepted, along with instructions on how to appeal for reconsideration.
Q. Once I've completed
credentialing, are my credentials good for the life of my contract?
A. No. The SJMMBH Credentialing Committee reviews your application every
two (2) years.
Q. What is the
SJMMBH Provider Participation Agreement?
A. Your SJMMBH Provider Participation Agreement is a contract between you
and SJMMBH to render behavioral health care services in accordance with
its terms to members whose care is managed by SJMMBH.
Q. If I sign the
Agreement, will I be eligible to see all members whose behavioral healthcare
is managed by SJMMBH?
A. Not necessarily. You must be credentialed by SJMMBH to be eligible to
treat SJMMBH members.
Q. How do I know
what SJMMBH lines of business I'm contracted for?
A. In states where the SJMMBH Provider Participation Agreement is in place,
the lines of business for which you are contracted for are based on the
reimbursement schedules included with your Agreement.
Q. Are my rates
negotiable?
A. No, individual rates are not negotiable.
Q. Are there different
reimbursement rates for different licensing levels?
A. Yes.
Q. When does my
contract become effective?
A. Your contract becomes effective on the date SJMMBH signs the agreement
or upon the effective date noted in the contract. Your contract will only
be executed after successfully completing the credentialing process.
Q. My Agreement
refers to the SJMMBH Provider Handbook for policies and procedures. Where
can I obtain this handbook?
A. The SJMMBH Provider Handbook may be accessed
on-line. This Web site also offers a host of other resources and applications
designed to make it easier for you to work with SJMMBH. To request a hardcopy
of these documents, contact SJMMBH Provider Relations.
What's the purpose of the Provider Data Change Form?
The Provider Data Change Form is designed
to enable you, the provider, to update the information that is stored
in your provider record here at SJMMBH. Through this application, you can
update information such as:
- address
- phone number
- fax number
- service locations
- Taxpayer Identification
Number
You may print out
this form and fax or mail it directly to SJMMBH.
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